Data Note: How Has the Individual Insurance Market Grown Under the Affordable Care Act?

The individual (or “non-group”) insurance market has changed substantially under the Affordable Care Act (ACA). Starting in 2014, the health law put in place new rules for what types of plans can be sold, required insurance companies to guarantee access to everyone regardless of health status, and limited the factors insurers could use in setting premiums. The law also created new Health Insurance Marketplaces, where low- and moderate- income consumers without access to other affordable coverage could obtain federal tax credits to help them pay their premiums.

As of the end of open enrollment in 2014, 8 million people had signed up for coverage through the Marketplaces. Accounting for the fact that some of those people did not pay their premiums or subsequently dropped coverage – and for signups through special enrollment periods throughout the year – 6.7 million people were insured through marketplace plans as of October 15, 2014. However, it has been unclear precisely how many of these Marketplace enrollees were previously uninsured or how many would have purchased individual coverage directly from an insurer in the absence of the ACA.

Kaiser Family Foundation analysis of recently-submitted 2014 filings by insurers to state insurance departments (using data compiled by Mark Farrah Associates) shows that 15.6 million people had major medical coverage in the individual insurance market – both inside and outside of the Marketplaces – as of December 31, 2014. Enrollment was up 4.9 million over the end of 2013, a 46% increase.

Individual Market Enrollment (in Millions)

The insurance company filings do not break down whether coverage was purchased through a Marketplace or in the outside market, nor whether coverage was first purchased after January 1, 2014 and therefore subject to the new ACA insurance market rules. However, juxtaposing these enrollment figures with the federal government’s estimate of 6.7 Marketplace enrollees as of October 15, 2014 suggests that about 43% of all individual market coverage was purchased through the marketplaces in 2014. It also means that new enrollment in the individual market among those who would have otherwise been uninsured likely took place inside the Marketplaces, driven by the availability of premium subsidies. Among those signing up for Marketplace plans in 2014, 85% qualified for premium subsidies.

Looking by state (shown in Table 1), almost half of the individual market enrollment growth nationwide from 2013 to 2014 was in four states: California (843,607), Florida (653,997), Texas (505,931), and Georgia (330,520). The individual insurance markets in six states grew by more than 75%: Arkansas (168%), New York (141%), Rhode Island (104%), Maine (93%), Georgia (79%), and Florida (77%). (Note that Arkansas figures may include some people eligible for Medicaid who enrolled in marketplace plans through that state’s “private option” approach to the ACA’s Medicaid expansion.)

Two states – Colorado and Massachusetts – saw decreases in individual market enrollment. Both states had below average enrollment in their marketplaces as a share of the potential market, and in Colorado some people previously purchasing coverage on their own may have switched to Medicaid as eligibility expanded. Massachusetts had implemented an earlier health reform plan and experienced significant transitions in coverage as the ACA took effect. (Note that the data for Nebraska also show a decrease in enrollment, but a sizable plan has not yet filed).

As of the end of open enrollment for 2015, 11.7 million people had signed up for Marketplace coverage, an increase of 3.7 million over 2014. Not all of those new enrollees will pay their premiums and begin coverage, but it is likely that the individual market has continued to grow in 2015, though at a slower pace than in the first year of full ACA implementation. Over time, reaching new enrollees – particularly those who are uninsured – will be key to the long-term success of the law.

Table 1: Change In Individual Market Enrollment From 2013-2014, by State

2014 Individual Enrollment

2013 Individual Enrollment

Change

% Change

National

15,553,564

10,620,872

4,932,392

46%

Alaska

23,641

14,127

9,514

67%

Alabama

205,772

168,787

36,985

22%

Arkansas*

303,258

113,288

189,970

168%

Arizona

327,549

266,381

61,168

23%

California

2,171,525

1,327,918

843,607

64%

Colorado

271,835

282,628

(10,793)

-4%

Connecticut

160,253

121,004

39,249

32%

District of Columbia

20,090

19,205

885

5%

Delaware

32,463

21,562

10,901

51%

Florida

1,499,569

845,572

653,997

77%

Georgia

750,256

419,736

330,520

79%

Hawaii

33,013

27,336

5,677

21%

Iowa*

189,264

181,159

8,105

4%

Idaho

150,065

90,810

59,255

65%

Illinois

599,188

442,703

156,485

35%

Indiana

231,276

171,525

59,751

35%

Kansas

163,952

124,619

39,333

32%

Kentucky

162,920

131,770

31,150

24%

Louisiana

224,989

175,218

49,771

28%

Massachusetts

72,208

79,233

(7,025)

-9%

Maryland

279,898

190,291

89,607

47%

Maine

61,807

31,965

29,842

93%

Michigan

473,091

344,173

128,918

37%

Minnesota

293,349

248,066

45,283

18%

Missouri

344,020

260,303

83,717

32%

Mississippi

128,189

85,190

42,999

50%

Montana

70,078

45,488

24,590

54%

North Carolina

633,480

467,868

165,612

35%

North Dakota

49,031

44,480

4,551

10%

Nebraska*

110,243

124,753

(14,510)

-12%

New Hampshire

55,611

35,856

19,755

55%

New Jersey

261,176

154,823

106,353

69%

New Mexico

70,525

57,508

13,017

23%

Nevada

118,296

96,694

21,602

22%

New York

410,924

170,680

240,244

141%

Ohio

380,508

330,617

49,891

15%

Oklahoma

171,673

121,897

49,776

41%

Oregon

210,211

160,047

50,164

31%

Pennsylvania

640,486

461,811

178,675

39%

Rhode Island

37,571

18,392

19,179

104%

South Carolina

201,111

134,210

66,901

50%

South Dakota

73,124

65,728

7,396

11%

Tennessee

340,904

243,143

97,761

40%

Texas

1,251,270

745,339

505,931

68%

Utah

213,830

140,084

73,746

53%

Virginia

416,010

317,414

98,596

31%

Vermont

32,163

21,115

11,048

52%

Washington

303,784

254,881

48,903

19%

Wisconsin

258,986

177,607

81,379

46%

West Virginia

42,225

24,665

17,560

71%

Wyoming

26,904

21,203

5,701

27%

Source: Kaiser Family Foundation analysis of annual filings to state insurance departments, using data compiled by Mark Farrah Associates. Enrollment as of December 31 of each year.Notes: Arkansas enrollment may include some people who enrolled in Medicaid through the state’s “private option” approach to Medicaid Expansion. Some known exchange participants have not filed enrollment data (Cooportunity Health in NE and IA, and Prominence Health Plan in NV). Data are still preliminary and other insurers may not have filed.

Methods

This analysis is based on filings that insurers submit to state regulators. The source of the data was the Health Coverage Portal TM, a market database maintained by Mark Farrah Associates, which includes information from the National Association of Insurance Commissioners and California’s Department of Managed Health Care. The underlying data sources are the Supplemental Health Care Exhibit (SHCE) and the California Department of Managed Care.

Plans showing enrollment, but no premium income were excluded from the analysis. In 2014, this primarily affected three states (Georgia, Kentucky, and Missouri), where Wellcare was excluded (this insurer primarily services Medicaid enrollees and appears to have erroneously filed as major medical). Parkland Community Health Plan was also excluded from Texas enrollment figures for this reason.

Some insurers have not yet filed certain data elements, or may revise their filings. Because some known exchange participants (in AR, CO, NM, NY, MA, OR, RI, UT, and WA) appear to have not filed the SHCE, these plans’ enrollment data as reported on the Exhibit of Premiums, Enrollment, and Utilization (EPEU) were used instead. Data for Affinity, HealthFirst, MetroPlus, and Fidelis Care in NY were provided by state regulators and are included in the updated version of this analysis. Exchange participants in other states did not have annual enrollment data available from either of the two exhibits (Cooportunity Health in NE and IA, and Prominence Health Plan in NV) and are therefore not included in this analysis.

Two sizable insurers (Blue Cross of Idaho and Security Health Plan of Wisconsin) did not file 2014 enrollment on the SHCE, so annual enrollment figures from the EPEU were used instead. In some cases, the number of individual market enrollees reported by individual insurers on the exhibits used for this analysis does not match figures reported on other exhibits.

Data were accessed on April 23, 2015. The analysis is limited to the 50 states and the District of Columbia, and does not include the territories. Enrollment is measured by the number of covered lives in major medical coverage on December 31, 2014, and does not include specialty coverage.